Download Tobacco/Smoking Cessation Improving Prenatal Care in Vermont Best Practice Provider Toolkit

Improving Prenatal Care in Vermont
Best Practice Provider Toolkit
Tobacco/Smoking Cessation
Tobacco Cessation Improvement Checklist
Greater than 18% of pregnant women in Vermont and more than 1/3 of low income women report smoking
tobacco during pregnancy (VDH, 2010), in comparison to a national rate of 13% in 2008 (HRSA, 2009). More
than two-thirds of those reporting smoking during pregnancy in Vermont do not quit – making Vermont the
second lowest in terms of mothers who quit smoking during pregnancy among states nationwide (VDH, 2008).
Vermont teens (age 15-19) are more than twice as likely to smoke during pregnancy as Vermont women
overall (VDH, 2008). Tobacco use is the single most preventable cause of low birth weight. The case and
subsequent guidelines regarding the importance of tobacco cessation have been well defined and supported
by research. Despite this fact, not all providers are aware of new guidelines, screening tools, interventions and
available community resources.
Though assessment is an important step toward encouraging tobacco cessation, it isn’t enough. A practice
level commitment to an effective tobacco cessation program is essential. The most important concept is to
utilize as many methods as possible to achieve the goal of cessation throughout pregnancy and beyond. Our
data did not reflect an improvement in this area, which confirms that ongoing and diligent work is needed.
Even minimal intervention (<3 minutes) advising the patient to quit smoking increases overall abstinence rates.
When considering referring pregnant women to your local QUITLINE, it is important to note that there is
specific program designed for pregnant women seeking advice and support for quitting.
Before the collaborative, I’d go into tobacco use fairly extensively at the initial prenatal visit. Then I might mention it four or five visits
later and ask how it’s going. Now, we’ve adopted the use of the stickers on the front of the chart, so we knew immediately that the patient
was a smoker. Each time they came into the office, my nurse would have a conversation with them about it and then I’d go in and have a
conversation about it. We probably were successful in achieving tobacco abstinence in a fair number of patients, but equally as important
– assuming they are reporting accurately – a high number of people cut way back with their tobacco use. (OB/GYN, rural practice)
Goals (developed in 2006 based on clinical guidelines HP 2010 and/or planning committee consensus)
1. 99% of pregnant women will be assessed for tobacco use at the first prenatal visit.
2. 99% of pregnant women identified as tobacco users will be offered in-office counseling at the first prenatal
visit.
3. 99% of pregnant women identified as tobacco users will be referred to a cessation program at the first
prenatal visit.
4. Greater than 50% of pregnant women identified as tobacco users will abstain from tobacco use by 28
weeks gestation.
Assessment
 Screen all patients at the first prenatal visit to identify smoking status, including those who quit within the
past year.
 Screen for environmental smoke exposure – in home, at work, in car.
 ASK, ADVISE and REFER. Often primary care offices have limited time so asking, advising and referring
patient to community resources, while offering ongoing positive support, will reinforce the quit message.
 If time allows, use the 5 A’s Model (Ask, Advise, Assess, Assist, Arrange). The Five A’s model for Smoking
(Stickers-Suckers-Smokers) helps to target the different stages of quitting. Using techniques such as
motivational interviewing, stages of change and assisting patients in setting self management goals can be
considered in collaboration with the community programs the patient is referred to.
 At every visit thereafter, re-screen women who currently smoke, those who have quit within the last year,
and/or those exposed to environmental tobacco smoke. Inquire after patient’s success, in linking with
community resources, while offering positive reinforcement and/or support for goals set and
accomplishments.
 Activate or establish a marker in your chart form or electronic patient record to identify the patient who is a
current smoker, or has been, in the last year. This will alert all staff to encourage the patients quit journey.
Intervention
Initial intervention should take 5-15 minutes. In-office counseling is the highest intervention priority.
 Intervene with current tobacco users and/or those women exposed to environmental smoke. If possible,
include family members in the discussion.
 Consider educational intervention for smokers who recently quit (within the past year) to help them remain
tobacco-free.
 Avoid using the fact that pregnant women who smoke often have babies born with a low birth weight. It
often has more impact if you describe the possible poor health outcomes for low birth weight infants such
as describing, “these babies are more difficult to care for, they cry more, are more often colicky and are
more often sick with illness such as ear infections and colds”.
 Set a goal to quit or reduce tobacco use to less than five cigarettes per day.
 Consider signing a contract with patient.
 Offer referral for partner and/or those living with a pregnant woman
 Hand out educational materials.
 Refer to 1(800) QUIT NOW (784-8669) or VTQuitNetwork.org. Patient can access a Quit Coach on-line
or by phone, get personal support, access self help tools and free nicotine replacement (gum, patches, or
lozenges) mailed to their door through the Vermont Department of Health. Telephone or in-person
counseling and support is particularly effective.
 Refer to online tracking program QUIT YOUR WAY. http://www.vtquitnetwork.org/quit-your-way
 Use Motivational Interviewing tactics (http://www.motivationalinterview.org/).
 Re-enforce and encourage the ‘Quit Message’ through each member of the practice team at every visit to
provide opportunities to offer positive reinforcement. All medical staff providing care for a pregnant woman
who is working to quit or has quit recently should be aware of the patients’ intervention plan and work to
engage and encourage the patient in this process.
 Make it clear to patients that they’re going to hear about quitting smoking every time they come in. Do this
to counteract any patient assumption that providers don’t want to hear about it.
 Reinforce risks of second hand smoke exposure before, during and after pregnancy.
 Consider Pharmacotherapy – Pharmacotherapy is recommended in the Surgeon General’s Guidelines
(http://www.surgeongeneral.gov/tobacco/), but the data for Pharmacotherapy has not been randomized.
These data are only suggestive enough to explore Pharmacotherapy with caution. For pregnant women,
we recommend pharmacotherapy as second line treatment for those unable to quit.
 Consider using an in-office motivational video with content that reinforces the quit message, outlines the
risks of smoking while pregnant and/or describes the health hazards of secondhand smoke.
Follow Up
 Review your office systems to establish a process for ensuring that, for those patient referred to the Quit
Network, the assessment follow-up fax from the Quit Network is placed/scanned into the patient’s chart
prior to her next prenatal visit. The QUITLINE fax will provide vital information as you begin your supportive
conversation.
 Be persistent in your encouragement of the patient’s commitment to quit or move towards quitting.
 Re-evaluate with patient any out-of-office referral for fit and effectiveness.
 Create a plan with the patient to eliminate environmental tobacco exposure for the pregnant mom and her
newborn infant.
Suggestions for Monitoring Your QI Efforts
To assess whether your intended change in practice is occurring and is being documented, regularly (i.e.,
quarterly) review patient charts within the first and third trimesters for the following indicators:
 Was the patient assessed for tobacco use at first prenatal visit?
 Was a 5 A’s model used for current smokers or women with a history of smoking within the last year?
 Was there documentation of setting a goal with patient to quit or reduce smoking, and/or reduce and then
eliminate exposure to environmental tobacco?
 Was there documentation of follow-up for out-of-office referrals, if applicable?
Resources
— www.surgeongeneral.gov/tobacco/
— Rocky Mountain Health Plans at www.rmhmo.org for “The 5 A’s (Stickers-Suckers-Smokers)”
— American Cancer Society and other cancer research and support centers
— Vermont Department of Health for links with resources such as VTQuitNetwork.org
— American Academy of Family Physicians “Ask and Act” Resources
www.aafp.org/online/en/home/clinical/publichealth/tobacco/askandact.html
— American College of Obstetrics and Gynecology (ACOG) at www.acog.org
- Smoking Cessation Homepage: acog.org/departments/dept_web.cfm?recno=13
- Visit acog.org/departments/dept_notice.cfm?recno=13&bulletin=1863 to obtain a tobacco
cessation toolkit for providers: Smoking Cessation During Pregnancy: A Clinician's Guide to
Helping Pregnant Women Quit Smoking. This free, CME-accredited guide outlines how to
integrate the "5 A's" into a clinical setting serving pregnant women. Includes algorithm of “5 A’s.”
- Free and interactive CME Smoking Cessation During Pregnancy video Training consistent with
USPHS 2008 Guidelines acog.org/departments/dept_web.cfm?recno=13
- Visit acog.org/departments/dept_notice.cfm?recno=13&bulletin=5025
- The guide includes a patient education workbook, “Need Help Putting Out that Cigarette?”.
Developed by Smoke Free Families (www.smokefreefamilies.org), this pregnancy-specific, selfhelp booklet includes information on ways to prepare to quit, setting a quit date, how to handle
"slips," and tips for staying smoke-free after the baby is born.
— National Guidelines Clearinghouse: www.guideline.gov/
— March of Dimes Web site: www.marchofdimes.com (English) or www.nacersano.org (Spanish). To
order a catalog or multiple copies of materials, call 1-802-560-4822.
— Agency for Healthcare Research and Quality. (AHRQ 2008) Helping Smokers Quit. A guide for
Providers http://www.ahrq.gov/path/tobacco.htm
— National Tobacco Cessation Collaborative. http://www.tobacco-cessation.org/
— What Works to Quit: A Guide to Quit Smoking Methods. http://whatworkstoquit.tobacco-cessation.org/
References
— Treating Tobacco Use and Dependence. 2008 Update. U.S. Public Health Service.
www.ncbi.nlm.gov/books/NBK12193.
— Vermont Department of Health (VDH), The Health Disparities of Vermonters. June 2010. Burlington,
VT.
— US Department of Health and Human Services, Health Resources and Services Administration
(HSRA), Maternal and Child Health Bureau. Women’s Health USA 2009. Rockville, Maryland: U.S.
Department of Health and Human Services, 2009.
— Vermont Department of Health (VDH),
www.healthvermont.gov/research/PRAMS/documents/20081222.pdf
— Vermont Department of Health (VDH). State of Vermont Tobacco Control Program Key Facts.
September 2008.
— Center for Disease Control and Prevention. Provider Fact Sheet: What to Tell Your Patient About
Smoking. http://www.cdc.gov/tobacco/data_statistics/sgr/2010/clinician_sheet/index.htm
Tobacco Cessation PDSA Example
Practice Name:
Date:
Cycle #:
Goal: Referrals for smoking cessation. (IPCV Charter goal: 99% of pregnant women who smoke will
be offered cessation materials and counseling or will be referred to a cessation program.)
Suggested measure: Want to make sure referrals are tracked for smoking cessation.
How do you plan to achieve this goal: By setting up better office flow for smoking cessation
referrals. First step we want to test is making sure documentation from provider for smoking
cessation referral is put in a place where someone can keep track of whether referral was completed.
_________________________________________________________________________
The PDSA CYCLE
The PDSA cycle is a simple yet powerful approach to moving from plan to action designed to help
you reach your improvement goal. PDSA cycles are small, rapid tests of change. They provide a
format to develop, test, and implement a change. These small steps lead to significant improvement.
How will you implement your plan?
Plan: (what, why)
What? Track patient referrals for smoking cessation by instituting a referral notice on chart that the
front office person will see.
Why? To make sure that women who want to quit smoking are able to receive referral services for
smoking cessation in a timely manner.
Do: (when, who, where)
Who? Provider and Front office person
When? Provider puts referral notice on chart at the end of the visit. When the patient checks out,
front office person sees notice and puts documentation in “Smoking Cessation Referrals” folder.
Where? Notice goes on outside of chart to be put in a folder labeled “Smoking Cessation Referrals”
that is kept on the front office desk.
Study: (intended results)
Smoking cessation referrals will be put in a folder in the front office to be reviewed at the end of each
week to update status of referral.
Act: (next step)
Cycle 2: Making sure that status of smoking cessation referral is being followed up.
Cycle 3: Making sure that status of referrals is documented in chart so that provider knows at next
prenatal visit if patient received referral services for smoking cessation.
Cycle 4: Making sure that billing person bills the insurance co. for smoking referral.
Stickers—Suckers—Smokers
Pregnancy Tobacco Cessation Program
“If you always do what you’ve always done,
then you’ll always get what you’ve always gotten!”
ASK
Ask at each visit about smoking status. Make it a part of checking routine vital signs.
OB TOBACCO CESSATION
 Have you ever smoked cigarettes?
Dare of visit
Cigarettes per day
 When was the last time you had a cigarette?
Counseled?
 How many cigarettes did you smoke yesterday?
Handouts given?
NRT or other Rx?
 Could you stop smoking just for your pregnancy?
Quit?
 Determine smoking status by reviewing history form filled out by patient.
 Place OB Tobacco Cessation sticker in chart.
 Congratulate patient if she stopped smoking when she found out she was pregnant.
ASSESS
Assess the willingness of the patient to attempt to quit within the next 30 days.
 How would quitting smoking improve your life?
 Are you interested in quitting with my help?
 If the patient is ready to quit, proceed to Assist.
If the patient is not ready, provide information to motivate the patient to quit; proceed to Arrange.
ADVISE
Advise patient to stop smoking. Message should be clear, strong, and personalized.
 The single most important thing you can do for your baby’s health is to stop smoking.
 I want to help you plan a smoke-free pregnancy.
ASSIST
Assist the patient in establishing a plan to stop smoking.
 Start a plan using “Need help Putting out That Cigarette?”
– Help patient choose a quit date. Offer Pledge Card.
– Have patient pick out smoking cessation method (cold turkey, tapering, etc.).
– Encourage support from family, friends, and coworkers.
– Highlight stress reduction activities.
 Introduce the 4 D’s (Delay, Drink Water, Deep Breathing, Do Something)
ARRANGE
Arrange for follow-up appointments or refer to a smoking cessation program and provide
support:
Vermont Quit Line – (800) QUITNOW (784-8669) or VTQuitNetwork.org
VDH Local Tobacco Cessation Contacts




It is imperative to send early OB referrals so the patient can start with smoking cessation
counseling early in pregnancy.
Consider nicotine replacement therapy.
Schedule a follow-up at each visit.
Ongoing Cessation Message: “I think you can do this. I’ll check your progress at the next
visit.”
Copyright 2000. Rocky Mountain Health Plans. Grand Junction, CO. Created by Janice Ferguson, RNC.
Reprinted with permission by Improving Prenatal Care in Vermont, Vermont Child Health Improvement Program, Burlington, VT
Page 2 of 2
Pregnancy Tobacco Cessation Program — Stages
Precontemplation
"No"
Contemplation
"Don't Know"
Not currently considering the
possibility of change.
Thinking about quitting
but takes no action to
do so.
Ready to quit and
preparing to change.
Engages in specific
actions intended to bring
about change.
“My mom smoked and we all
turned out fine.”
“I’m worried about the
effects on my baby.
Maybe I should quit or
cut down...”
“I’m gonna quit by my
next prenatal check-up.
Tell me how to do it.”
“I haven’t had a cigarette
since the last visit.”
“Can you stop just for your
pregnancy?”
Encourage patient to
consider trying to stop
smoking.
Congratulate patient on
her decision to quit. Let
her know you’re there
to support her.
Continually assess how
smoking cessation plan is
working and give
feedback every visit.
Encourage support from
family, friends, and
coworkers.
Pay attention to what
triggers smoking and
praise for healthy
replacement behaviors.
“The single most important
thing you can do for yourself
and your baby’s health is to
stop smoking.”
Think of a “No” as a “No on
the way to a Yes” that can be
influenced by your
counseling.
Let the patient know you
support her in whatever
decision she makes.
Try to motivate an attempt to
quit.
Let her know you have
confidence in her.
Explore the benefits and
drawbacks of
continuing to smoke
and of quitting. (Use the
“Pros and Cons of
Quitting Smoking”
worksheet).
Give feedback and
education about
patient’s smoking.
Preparation
"Yes"
Help her take
preparatory steps and
find healthy
replacement behaviors.
(Use the “Do other
things instead of
Smoking” worksheet.)
Focus less on the
problem and more on
the solution and action
plan. (Use the “Coping
with Withdrawal
Symptoms” worksheet.)
Action
"Go!"
This stage takes the
greatest amount of
commitment of time and
energy. (Use the “Coping
with Withdrawal
Symptoms” worksheet.)
Maintenance
"Cruising"
Relapse
"Backslide"
Attempts to sustain
the change
accomplished by
previous action and
to prevent relapse.
“I haven’t had a
cigarette in almost a
year.”
Returns to an earlier
stage of change,
often to
precontemplation.
Tobacco free for
duration of pregnancy.
“My stress levels are
too high.”
“I don’t even think
about smoking
anymore.”
Reinforce patient’s
success.
Reframe relapse as
an opportunity to
learn and not a
reason to fail.
Use her success with
smoking cessation to
support selfempowerment. Remind
her that quitting was
probably one of the
hardest things she will
ever do.
If there are
significant life
changes or stressors,
reassess triggers and
continuance of
healthy replacement
behaviors.
Focus on successes
and what worked.
Re-evaluate her stage
of change and assist
her to re-enter the
change cycle.
Encourage patient to
reward herself for her
efforts.
Rocky Mountain Health Plans. Grand Junction, CO. Created by Janice Ferguson, RNC
Reprinted with permission by Improving Prenatal Care in Vermont, Vermont Child Health Improvement Program, Burlington, VT. Last reviewed 2011.
Page 9
Self-Empowerment
"Finish"
Raise awareness about
handling periods of
stress and situations that
trigger tobacco use.
Encourage remaining
smoke-free after
delivery. Review effects
of second-hand smoke
on children.
Page 1 of 4
The Pros & Cons of Quitting Smoking
Check the ones that apply to you.
Benefits of Smoking:
Helps you:





Cope with stress
Relax
Concentrate
Deal with boredom
Handle strong emotions like anger,
anxiety, sadness
 Deal with physical discomfort
 Source of pleasure
 Source of comfort
 Reward
 Social tool with other smokers
 Buffer between you and the world
Benefits of Quitting:
 Healthier baby
 Reduce risk of maternal complications
Drawbacks of Smoking:
 The risk of miscarriage, prematurity, and
stillbirth is up to twice as high for smokers.
 The risk of a low birth weight baby is higher for
mothers who smoke. These babies are more
difficult to care for, they cry more, are more
often colicky and are more often sick with
illness such as ear infections and colds
 Babies born to mothers who smoke are more
susceptible to respiratory infections and are
hospitalized more frequently.
 Studies have shown that babies lose 4 points in
their IQ if the mother smokes.
 Increased risk of maternal complications
 Cost
 Poor role model for children
 Possibly hurting the health of family members
 Discolors your teeth
 Makes your hair and clothes smell
 Freedom from worry about your health,
your family’s health
 Wrinkles your skin
 Family can stop worrying about you
 Coughing, shortness of breath, lack of energy
 People will stop nagging you
 Blunted sense of taste and smell
 Able to go into public places without
being self-conscious, without hassles
Drawbacks of Quitting:
 Feel better physically, more energy
 Put up with cravings
 Increased self-esteem
 Not feel like yourself for a while
 Increased confidence that you can make
things happen in your life
 May gain weight, at least temporarily (it’s okay
to gain weight during your pregnancy)
 More spending money: $500-$1000+
each year
 Relationships with friends who smoke may
change
 More time to do other things you want to
do
 Worry about whether you’ll succeed
Adapted with permission from Rocky Mountain Health
Plans. Grand Junction, CO. 2004. Reprinted by
Improving Prenatal Care in Vermont, Vermont Child
Health Improvement Program, Burlington, VT. Last
reviewed 2011.
Page 10
 Uncomfortable period of physical withdrawal
 May feel uncomfortable, unhappy, sorry for
yourself
 Must give up something that is very precious to
you
Page 2 of 4
Do Other Things Instead of Smoking
When you get the urge to smoke, do something else instead:
 Think of the good you are doing for your baby
 Take a walk
 Go shopping (buy something special for the baby)
 Walk into another room or step outside and count to 20
 Call your Stop Smoking Buddy or a friend who will give you good support
 Leave the table after eating
 Take a nap
 Practice deep breathing
 Count your baby’s movements
 Take a warm bubble bath or shower
 Drink a glass of water or juice
 Read a baby magazine or a health magazine
 Clean the house
 Open the windows and enjoy the fresh air
 Rinse your mouth with mouthwash or brush your teeth
 Start a new hobby that keeps your hands busy
 Finish an old project
 Play a game
 Eat some low-calorie fruits and vegetables
 Chew sugarless gum or suck on sugarless candy
 Go to a movie
 Congratulate yourself on your efforts to quit smoking
Other things I can do to keep from lighting a cigarette:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Adapted with permission from Rocky Mountain Health Plans. Grand Junction, CO. 2004.
Reprinted by Improving Prenatal Care in Vermont, Vermont Child Health Improvement Program, Burlington, VT.
Last reviewed 2011.
Page 11
Page 3 of 4
Coping With Withdrawal Symptoms
Signs of Recovery
Listed below are symptoms of recovery that may occur a few days or weeks after quitting smoking, with suggestions
on how to handle them. REMEMBER, they are normal and temporary.
How You May Feel
Why It May Happen
What to Do About It
Irritable, nervous, anxious, grumpy
No more nicotine, losing the crutch of
cigarettes
Take it easy. Avoid stressful situations.
Warn those around you. Get enough rest.
Do whatever is relaxing for you. Exercise.
Unable to concentrate, less
efficient, impaired speech, lack of
coordination, feeling spaced out or
in a fog.
Withdrawal from carbon monoxide
(poisonous gas) and nicotine
Breathe deeply. Take a walk. Be careful
using equipment or driving. Take time off
if necessary. Don’t expect too much of
yourself – especially the first 3 days.
Lightheaded, dizzy, feeling overstimulated
More oxygen in blood, less carbon
monoxide
Sit down. Relax. Consider it a high.
Sleepy, weak, no energy
No more nicotine for stimulation
Wake up with deep breathing and
exercise. Get extra sleep and take naps.
Enjoy feeling relaxed. Take it easy.
Insomnia or other sleep
disturbances
Change in daily routine, body may
need less sleep
Use more energy during the day. Relax
before bed with deep muscle relaxation
and a warm bath. Enjoy the extra hours
you aren’t sleeping.
Hungry
Nicotine artificially suppresses
appetite
Recognize these feelings may not be due
to hunger. Don’t eat more (except for lowcalorie snacks like carrot sticks).
Exercise. Drink water.
Increased coughing
Excess mucus and tar in the lungs
being cleared out
Be glad your lungs are getting clean.
Constipated
Decreased intestinal activity
Eating fiber or roughage foods like fresh
fruits and vegetables, whole grains, and
bran.
Headache
Better circulation sends more blood to
the brain
Lie down, relax.
Irritated or itchy scalp, hands
and/or feet
Better blood circulation to your
extremities
Massage the area.
Tremors, shaky
Nicotine withdrawal
Sit down. Flex and relax muscles.
Sweaty
Body’s way of flushing out nicotine
Take more showers!
Increased need to urinate
Body’s way of getting rid of nicotine
or from drinking more fluids
Go with it. Be glad your body is flushing
out the poison.
Mouth sores, bad taste, sore gums
or tongue, dry tongue
May be due to chemicals in cigarettes
needed to counteract nicotine
Use mouthwash or oral antiseptics.
Strong emotions
Nicotine no longer deadens your
feelings
Accept feelings as natural. To keep them
in control, pause, breathe deeply, and
relax.
Dreams of smoking
Be glad you don’t really smoke!
Adapted with permission from Rocky Mountain Health Plans. Grand Junction, CO. 2004.
Reprinted by Improving Prenatal Care in Vermont, Vermont Child Health Improvement Program, Burlington, VT.
Last reviewed 2011.
Page 12
Page 4 of 4
For People Who Still Smoke
Your support is particularly important to someone who is trying to quit smoking. Thank you for caring and being
available for your friend or loved one. Here are some support tips:
 Consider quitting yourself – especially if you have thought about doing it in the past. Then the two of you
can support and encourage each other, and your chances of success are improved.
 Don’t smoke in the ex-smoker’s presence – it will make it harder for him/her to resist smoking. If you
must smoke when you’re around an ex-smoker, excuse yourself and smoke somewhere else.
 Put your cigarettes, ashtrays, lighters, and other smoking paraphernalia out of sight. These can tempt
your friend or loved one to smoke.
 Sit down and talk with each other to find out how you might provide support. Show you care. Be clear
about what you are willing and not willing to do.
 List the different kinds of support you would be willing to offer:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
 Invite your friend or loved one to make his/her own wish list for support. Compare your lists and come up
with a plan that works for you both.
REMEMBER, you can play an important role
in your someone’s efforts to quit smoking.
Adapted with permission from Rocky Mountain Health Plans. Grand Junction, CO. 2004.
Reprinted by Improving Prenatal Care in Vermont, Vermont Child Health Improvement Program, Burlington, VT.
Last reviewed 2011.
Page 13
Tobacco Treatment Flow Sheet
Medical Record or Account #:
DOB:
Page 1 of 2
Name (F/M/L):
ASK – Identify the patient’s current smoking status and exposure to second-hand smoke
 Yes
 No
Household Tobacco: Number of smokers other than patient:
Baseline Tobacco Status ( one best statement)
 1. Never smoked or smoked < 100 cigarettes in lifetime
Congratulate. STOP
 2. Quit 12 months ago or more – not smoking now.
Congratulate & encourage staying quit. STOP
Type:
 3. Quit less than 12 months ago – not smoking now.
Congratulate & encourage staying quit. CONTINUE
 4. Quit during this pregnancy
Congratulate & encourage staying quit. CONTINUE
 5. Currently Smoking
CONTINUE
Co-morbidities:
 Depression
 EtOH

Partner smokes:
 Cigarette
 Other
Amount per day:
Age Began:
Quit History (dates, success, challenges etc.):
If currently smoking, quit during pregnancy or less than 12 months ago, complete the section below at each visit:
VISIT DATE









Check if Post Partum Visit
Prescribed
CHECK SMOKING STATUS (ASK)
Quit during pregnancy
Currently Smoking
ASSESS interest in quitting (Pregnancy Tobacco Cessation Program – Stages)
Ready to quit now (within next 30 days)
Not ready to quit now
ADVISE, ASSIST, and ARRANGE
Provide health message; discuss benefits of
quitting: If intending to quit, advise “NO tobacco”.
If not intending to quit: “Think about trying to quit.”
Self-Help brochures
VTQuitNetwork.org or 1-800-Quit-Now (784-8669)
Short Quit Plan – You Can Quit Smoking
Quit Plan – Need Help Putting Out that Cig?
Medications discussed
Buproprion
NRT – Gum
NRT – Inhaler
NRT – Lozenge
NRT – Patch
Other
Adapted with permission from the NICHQ. 2004. Printed by Improving Prenatal Care in Vermont, Vermont Child Health Improvement Program, Burlington, VT. Last reviewed 2011.
Page 14

Drug
Nicotine Gum
(OTC)
Nicotine lozenge
(OTC)
Nicotine patch
(Nicotine CQ and Nicotrol
OTC generic patches by
prescription)
Nicotine nasal spray
(prescription)
Nicotine inhaler
(prescription)
Bupropion sustained release
(prescription)
Quick Guide to Smoking Cessation Pharmacotherapy
Page 2 of 2
Dosing
Instructions
2-mg and 4-mg pieces to be used on a schedule or as Chew the gum slowly until the taste of mint
needed. The 4-mg gum is recommended for people
or pepper occurs. Then park the gum
who smoke > 25 cigarettes/day. Scheduled use (q 1-2 between the cheek and gum to permit
hours) for 1 to 3 months may be better than asabsorption through the oral mucosa.
needed use.
Repeat and continue for approximately 30
minutes. Avoid acidic beverages (coffee,
juice, soft drinks) or eating for 15 minutes
before and during use.
2-mg lozenge (for those who smoke their first
Avoid eating or drinking for 15 minutes
cigarette after 30 minutes of waking) and 4-mg
before use. Suck on the lozenge until it
lozenge (for those who smoke their first cigarette
dissolves. Do not bite or chew it like a hard
within 30 minutes of waking). The recommended
candy, and do not swallow it.
dosing scheme is 1 lozenge: every 1-2 hours for
weeks 1-6, every 2-4 hours during weeks 10-12.
Recommended length of therapy is 12 weeks
One patch every day. Nicoderm CQ is 1 24-hour
At the start of each day, place a fresh patch
patch that comes in 3 doses for tapering. The
on a relatively hairless area of skin
recommended dosing scheme is 21 mg for 4 weeks,
between the waist and neck. If sleep
14 mg for 2 weeks, and 7 mg for 2 weeks. Nicotrol is a disruption occurs, the patch may be worn
16-hour patch that comes in 15 mg for 8 weeks.
only during waking hours.
One spray to each nostril (1 mg total nicotine). Initial
Avoid sniffing, inhaling, or swallowing
dose is 1-2 doses per hour, as needed, for symptom
during administration as irritating effects
relief. Minimum treatment is 8 doses/day. The
are increased. Tilt the head back slightly
maximum is 40 doses/day and 5 doses/hour. Each
during administration.
bottle contains 100 mg of nicotine.
One puff as needed. A cartridge delivers 4 mg of
Temperatures below 40 degrees F
nicotine in the course of 80 inhalations. 6-16
decrease nicotine delivery. Avoid acidic
cartridges should be used per day, with tapering of
beverages or eating for 15 minutes before
use in the last 6-8 weeks of therapy.
use. Duration of therapy is for up to 6
months.
150 mg BID, beginning qAM x 3 days
Begin bupropion 1-2 weeks before the quit
date. The duration of therapy is 7-12 weeks
and may be extended up to 6 months.
Inclusion of this adult dosage chart is strictly for the convenience of the prescribing provider. Please consult the Physicians’ Desk
Reference for complete product information and contraindications.
Page 15
Vermont Tobacco Cessation Contacts
Organization
Brattleboro Memorial Hospital
Local Contact
Phone
E mail
257-8218
Central Vermont Medical Center
Bob St. Pierre
Loretta Schneider
Gigi Magee
Copley Hospital
Lawrence Berry
[email protected]
Department of Veterans Affairs
Spencer Burdge
888-8324
295-9363
x5760
Fletcher Allen Health Care
Gifford Medical Center
Evelyn Sikorski
Glenda Mitroff
Susan Delattre
847-6540
728-2349
728-2118
[email protected]
[email protected]
[email protected]
Mt. Ascutney Hospital
Melanie Peet Sheehan
674-7089
[email protected]
North Country Hospital
Joanne Fedele
334-3208
[email protected]
Northwestern Medical Center
Northeastern Vermont Regional
Hospital
Jamie Balch
524-1296
[email protected]
Diane Matthews
748-7304
[email protected]
Porter Medical Center
Heidi Sulis
388-4739
[email protected]
Rutland Regional Medical Center
Southwestern Vermont Medical
Center
Peg Young
747-3768
[email protected]
Gwen Hannan
[email protected]
Springfield Hospital
Mary Anne Riley
447-5508
885-2151
x155
Statewide Cessation Coordinator
VAHHS Statewide Administrative
Liaison
Catherine Suiter
847-6574
[email protected]
Penrose Jackson
847-3445
[email protected]
371-5903
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Printed by Improving Prenatal Care in Vermont, Vermont Child Health Improvement Program, Burlington, VT.
Last reviewed 2011.
Patient Name:___________________________________
DOB:__________________
Visit date:_____________ Name of smoker_____________________
Chart #:______________________
Visit date:_____________ Name of smoker_____________________
Tobacco Treatment Checklist
Stop-smoking advice given: “I strongly
ADVISE
advise that you establish a no-smoking
smoker to
policy in the house and that you quit
stop:
smoking yourself and I can help you”
Tobacco Treatment Checklist
Stop-smoking advice given: “I strongly
ADVISE
advise that you establish a no-smoking
smoker to
policy in the house and that you quit
stop:
smoking yourself and I can help you”
ASSESS
readiness
to quit:
Ready to quit
Thinking about quitting
Not ready to quit
ASSESS
readiness
to quit:
Ready to quit
Thinking about quitting
Not ready to quit
ASSIST
smoker to
quit:
Brief counseling
Help with a quit plan
Reasons to quit; Clarify the goal of complete
abstinence
Barriers to quitting
Lessons from past quit attempts
Identify triggers and difficult situations and
consider coping strategies
Enlist social support
Medications if appropriate
Prescribe pharmacotherapy (patch, gum, lozenge,
nasal spray, inhaler, bupropion-SR)
Provide supplementary educational materials
ASSIST
smoker to
quit:
Brief counseling
Help with a quit plan
Reasons to quit; Clarify the goal of complete
abstinence
Barriers to quitting
Lessons from past quit attempts
Identify triggers and difficult situations and
consider coping strategies
Enlist social support
Medications if appropriate
Prescribe pharmacotherapy (patch, gum, lozenge,
nasal spray, inhaler, bupropion-SR)
Provide supplementary educational materials
ARRANGE
follow-up:
Refer to: _______________________________
ARRANGE
follow-up:
Refer to: _______________________________
Counseling notes: ____________________________________
Counseling notes: ____________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Visit date:_____________ Name of smoker_____________________
Visit date:_____________ Name of smoker_____________________
Tobacco Treatment Checklist
Stop-smoking advice given: “I strongly
ADVISE
advise that you establish a no-smoking
smoker to
policy in the house and that you quit
stop:
smoking yourself and I can help you”
Tobacco Treatment Checklist
Stop-smoking advice given: “I strongly
ADVISE
advise that you establish a no-smoking
smoker to
policy in the house and that you quit
stop:
smoking yourself and I can help you”
ASSESS
readiness
to quit:
Ready to quit
Thinking about quitting
Not ready to quit
ASSESS
readiness
to quit:
Ready to quit
Thinking about quitting
Not ready to quit
ASSIST
smoker to
quit:
Brief counseling
Help with a quit plan
Reasons to quit; Clarify the goal of complete
abstinence
Barriers to quitting
Lessons from past quit attempts
Identify triggers and difficult situations and
consider coping strategies
Enlist social support
Medications if appropriate
Prescribe pharmacotherapy (patch, gum, lozenge,
nasal spray, inhaler, bupropion-SR)
Provide supplementary educational materials
ASSIST
smoker to
quit:
Brief counseling
Help with a quit plan
Reasons to quit; Clarify the goal of complete
abstinence
Barriers to quitting
Lessons from past quit attempts
Identify triggers and difficult situations and
consider coping strategies
Enlist social support
Medications if appropriate
Prescribe pharmacotherapy (patch, gum, lozenge,
nasal spray, inhaler, bupropion-SR)
Provide supplementary educational materials
ARRANGE
follow-up:
Refer to: _______________________________
ARRANGE
follow-up:
Refer to: _______________________________
Counseling notes: ____________________________________
Counseling notes: ____________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
2003 National Initiative for Children’s Healthcare Quality
Quick Guide to Smoking Cessation Pharmacotherapy
Drug
Dosing
Instructions
Nicotine gum
2-mg and 4-mg pieces to be used on a
schedule or as needed. The 4-mg gum
is recommended for people who smoke
> 25 cigarettes/day. Up to 24 pieces of
gum may be used daily. Scheduled use
(q 1-2 hours) for 1 to 3 months may be
better than as-needed use.
Chew the gum slowly until the taste of
mint or pepper occurs. Then park the
gum between the cheek and gum to
permit absorption through the oral
mucosa. Repeat and continue for
approximately 30 minutes. Avoid acidic
beverages (coffee, juice, soft drinks) or
eating for 15 minutes before and during
use.
2-mg lozenge (for those who smoke
their first cigarette after 30 minutes of
waking) and 4-mg lozenge (for those
who smoke their first cigarette within 30
minutes of waking up). The
recommended dosing scheme is 1
lozenge: every 1-2 hours for weeks 1 - 6,
every 2 - 4 hours during weeks 7 – 9, and
4 - 8 hours during weeks 10 - 12.
Recommended length of therapy is 12
weeks.
Avoid eating or drinking for 15 minutes
before use. Suck on the lozenge until it
dissolves. Do not bite or chew it like a
hard candy, and do not swallow it.
One patch every day. Nicoderm CQ is
a 24-hour patch that comes in 3 doses
for tapering. The recommended dosing
scheme is 21 mg for 4 weeks, 14 mg for
2 weeks, and 7 mg for 2 weeks. Nicotrol
is a 16-hour patch that comes in 15 mg
for 8 weeks.
At the start of each day, place a fresh
patch on a relatively hairless area of
skin between the waist and neck. If
sleep disruption occurs, the patch may
be worn only during waking hours.
One spray to each nostril (1 mg total
nicotine). Initial dose is 1-2 doses per
hour, as needed, for symptom relief.
Minimum treatment is 8 doses/day. The
maximum is 40 doses/day and 5
doses/hour. Each bottle contains 100
mg of nicotine.
Avoid sniffing, inhaling, or swallowing
during administration as irritating effects
are increased. Tilt the head back slightly
during administration.
One puff as needed. A cartridge
delivers 4 mg of nicotine in the course of
80 inhalations. 6-16 cartridges should be
used per day, with tapering of use in the
last 6-12 weeks of therapy.
Temperatures below 40°F decrease
nicotine delivery. Avoid acidic
beverages or eating for 15 minutes
before r use. Duration of therapy is for
up to 6 months.
150 mg BID, beginning qAM × 3 days
Begin bupropion 1-2 weeks before the
quit date. The duration of therapy is 712 weeks and may be extended up to 6
months.
(OTC)
Nicotine lozenge
(OTC)
Nicotine patch
(Nicoderm CQ and
Nicotrol OTC,
generic patches by
prescription)
Nicotine nasal spray
(prescription)
Nicotine inhaler
(prescription)
Bupropion sustained
release
(prescription)
Inclusion of this adult dosage chart is strictly for the convenience of the prescribing provider. Please consult the Physicians’ Desk
Reference for complete product information and contraindications.
2003 National Initiative for Children’s Healthcare Quality
= BEST
= BETTER
= GOOD
= OK
= NO EVIDENCE THAT THIS
TREATMENT IS EFFECTIVE
A Guide to Quit Smoking Methods
WHAT CAN HELP ME TO QUIT?
HOW WELL
DOES IT WORK?
HOW MUCH DOES
IT COST TO QUIT?1
DOES INSURANCE
COVER IT?
COST TO QUIT:1
$
= under $150
$$ = $151 - $299
$$$ = $300 and above
WHERE CAN I GET IT?
Counseling and Support
Counseling and Support—In Person
(Individual or Group)
$ to $$$
Counseling and Support—Telephone
Free
Your doctor, clinic, hospital or health
department
no cost
Your state or local health department
or quitline, such as 1-800-QUIT-NOW
Medications (Common Brand Names)
Bupropion SR Pills (Wellbutrin® or Zyban®)2
Nicotine Gum (Nicorette®)
2
Your doctor; 1-800-QUIT-NOW3
Free to $$$3
Free to $$$
Over-the-counter; 1-800-QUIT-NOW3
3
Nicotine Inhaler (Nicotrol® Inhaler)
$$$
Your doctor
Nicotine Lozenge (Commit®)2
Free to $$$3
Over-the-counter; 1-800-QUIT-NOW3
Nicotine Nasal Spray (Nicotrol®)
$$ to $$$
Your doctor
Nicotine Patch (Nicoderm CQ®)
Free to $$
Varenicline Pills (Chantix®)
$$ to $$$
Your doctor
Combined Nicotine Replacement Therapies
$ to $$$
Over-the-counter; 1-800-QUIT-NOW3; Your doctor
In-Person Counseling and Support
+ Medication
$ to $$$
Your doctor, clinic, hospital or health
department
Telephone Counseling and Support
+ Medication
Free to $$$3
1-800-QUIT-NOW3
Acupuncture
$$$
Licensed Acupuncturist
Hypnosis
$$$
National Board Certified Hypnotherapist
Laser Therapy
$$$
2
Over-the-counter; 1-800-QUIT-NOW3
3
Combination Methods
Other Methods
Internet Quitting Programs
Self-help Quitting Guides and
Other Materials
1 Cost may be free or significantly reduced if your insurance,
health plan, quitline or clinic provides coverage.
2 Generic versions, store brands and other brands are available.
3 Many quitlines provide free or low-cost medication to eligible adults.
Check with your quitline.
Free
Free to $
Laser therapist
no cost
TALK WITH YOUR DOCTOR OR PHARMACIST BEFORE BEGINNING ANY MEDICATIONS.
For more information, please visit
http://whatworkstoquit.tobacco-cessation.org
Online; www.smokefree.gov
Your doctor, other health care provider
or health department
= YES, often covered. Check with your insurance company
or health plan.
EPA 402/F/09/004 | September 2009 | www.epa.gov/iaq
Secondhand Smoke is
Dangerous
Secondhand
Tobacco Smoke
and the Health of
Your Family
Everyone knows that smoking is bad for
smokers, but did you know:
• Breathing in someone else’s
cigarette, pipe or cigar smoke can
make you and your children sick.
• Children who live in homes where
people smoke may get sick more
often with coughs, wheezing, ear
infections, bronchitis or pneumonia.
Protect Your Family
• Make your car and home smoke-free.
• Family, friends or visitors should never
smoke inside your home or car.
• Keep yourself and your children away
from places where smoking is allowed.
• If you smoke, smoke only outside.
• Ask your doctor for ways to help you
stop smoking.
• Children with asthma may have
asthma attacks that are more severe
or occur more often.
• Opening windows or using fans
or air conditioners will not stop
Keeping a smoke-free home
secondhand smoke exposure.
and car can help improve
• The U.S. Surgeon General says
that secondhand smoke can cause
Sudden Infant Death Syndrome, also
Make Your Home and Car
Smoke-Free
Secondhand smoke is the smoke that
comes from the burning end of a cigarette,
cigar or pipe. Secondhand smoke can
make you and your children sick.
Remember
your health, the health of your
children and the health of
your community.
known as SIDS.
• Secondhand smoke also can cause
lung cancer and heart disease.
Indoor Air Quality (IAQ)
El humo de segunda mano es
peligroso
Todo el mundo sabe que fumar es malo
El humo de tabaco
en el medio
ambiente y la
salud de su familia
para los fumadores, pero ¿tenia usted
conocimiento?
• Respirar el humo que sale del cigarrillo
de una pipa o puro puede enfermarlo a
usted y a sus niños.
• Los niños que viven en casas donde las
personas fuman se pueden enfermar
más a menudo con tos, respirar
condificultad, infecciones de oído,
bronquitis o pulmonía.
Proteja a su familia
• Mantenga su hogar y su automóvil
libres del humo de segunda mano.
• Su familia, amigos o visitantes no
deben nunca fumar en el interior de su
hogar ni de su automóvil.
• Manténgase al igual que a sus niños
alejados de los lugares donde es
permitido fumar.
• Si usted fuma, fume afuera solamente.
• Pídale a su médico que le diga formas
de como dejar de fumar.
• Los niños con asma pueden sufrir de
ataques de asma más severo y con más
frecuencia.
• Abrir las ventanas, usar abanicos o
aires acondicionados no reducirá por
complete el humo de segunda mano.
Mantenga su hogar y su auto
libres del humo de tabaco
El humo de segunda mano es el humo
que sale de un cigarrillo, de un puro,
o de una pipa. El humo de segunda
mano puede enfermarlo a usted y a sus
niños.
• El Cirujano General de los E.U. dice
que el humo de segunda mano puede
Recuerde
Mantener a su hogar y su
automóvil libres del humo de
segunda mano puede mejorar
su salud, la de sus niños
y la de su
comunidad.
causar el síndrome de muerte súbita
(SIDS, por sus siglas en inglés).
• El humo de segunda mano
puede causar cáncer pulmonar y
enfermedades del corazón.
Indoor Air Quality (IAQ)